Azalea Trail Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Azalea Trail Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Jul 29, 2026

  Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one (Resident #1) of three residents reviewed for oxygen use. The facility failed to securely store oxygen cylinder when in resident room on 7/27/26. This failure could place residents at risk of living in an unsafe environment. Findings included: 1. A record review of Resident #1's face sheet, dated 07/28/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF656Nov 19, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to care plan the bed alarm being discontinued on 07/21/25 for Resident #1. The facility failed to care plan Resident #1's fall with major injuries on 08/06/25. These failures could place residents at risk of not having individual needs met and not receiving needed services. […]

• No harm, potential for more than minimal, isolatedF657Nov 17, 2021

  Based on observation, interview and record review, the facility failed to review and revise the person-centered care plan for 1 of 2 residents reviewed for care plans. (resident#13) The facility did not revise Residents #13's care plan to include her actual indwelling catheter. This failure could place residents at risk for decreased quality of care and life. Finding included: Record Review of a Matrix for providers (used to identify pertinent care categories) dated 11/2020 indicated Resident #13 did not have an indwelling Catheter. Record Review of an MDS dated [DATE] indicated Resident #13 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF800Nov 17, 2021

  Based on interview and record review, the facility failed to provide a diet to met the needs of 1 of 17 residents reviewed for physician orders. (Resident #8) The facility failed to ensure Resident #8 received magic cup and yogurt with every meal as ordered by the physician. This failure could place residents at risk for not receiving appropriate treatment and services to meet their needs. Findings included: Record review of the physician order dated November 2021 indicated Resident #8 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes, anorexia, and cerebral infarction (stroke). […]

• No harm, potential for more than minimal, isolatedF842Nov 17, 2021

  Based on observation, interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 2 of 17 residents reviewed for accuracy and completeness. (Resident #s 8 and 15) Resident #8's care plan inaccurately reflected she was taking an anticoagulant when she was not. Resident #15's care plan inaccurately reflected she had a foley catheter when she did not have one. […]